| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
900 |
382 |
$42K |
| D1110 |
Prophylaxis - adult |
584 |
549 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
495 |
471 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
676 |
640 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
131 |
$9K |
| D0274 |
Bitewings - four radiographic images |
498 |
453 |
$8K |
| D1206 |
Topical application of fluoride varnish |
635 |
611 |
$8K |
| D1120 |
Prophylaxis - child |
425 |
409 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
42 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
104 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
327 |
$2K |